401k Plan data: B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT plan

B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT 401k Plan overview

Plan Name	B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT
Plan identification number	501

B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

B.WELL CONNECTED HEALTH, INC has sponsored the creation of one or more 401k plans.

Company Name: B.WELL CONNECTED HEALTH, INC

Employer identification number (EIN): 473885665

NAIC Classification: 524290

Form 5500 Filing Information

Submission information for form 5500 for 401k plan B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-06-01

Plan Statistics for B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT

401k plan membership statisitcs for B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT

Measure Date Value
2022: B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT 2022 401k membership
Total participants, beginning-of-year 2022-06-01 119
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 119
Number of retired or separated participants receiving benefits 2022-06-01 0
Number of other retired or separated participants entitled to future benefits 2022-06-01 0
Total of all active and inactive participants 2022-06-01 119

Measure	Date	Value
2022: B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT 2022 401k membership
Total participants, beginning-of-year	2022-06-01	119
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	119
Number of retired or separated participants receiving benefits	2022-06-01	0
Number of other retired or separated participants entitled to future benefits	2022-06-01	0
Total of all active and inactive participants	2022-06-01	119

Form 5500 Responses for B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT

2022: B.WELL CONNECTED HEALTH WRAP PLAN DOCUMENT 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	First time form 5500 has been submitted	Yes
2022-06-01	Submission has been amended	No
2022-06-01	This submission is the final filing	No
2022-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-06-01	Plan is a collectively bargained plan	No
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00636317

Policy instance

Insurance contract or identification number	00636317
Number of Individuals Covered	187
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $46,991
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $451,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $46,991
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000C4MS

Policy instance

Insurance contract or identification number	G000C4MS
Number of Individuals Covered	119
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $8,751
Total amount of fees paid to insurance company	USD $3,988
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $70,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,751
Amount paid for insurance broker fees	381
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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Company Name:	B.WELL CONNECTED HEALTH, INC
Employer identification number (EIN):	473885665
NAIC Classification:	524290